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P-Drugs & P-Treatment

Setyawati S Karyono Pharmacology Department Medical Faculty Brawijaya University

Example: patient 1 (G to GP) You sit in with a general practitioner and observe the following case : A 52-year old taxi-driver complains of a sore throat and cough which started two weeks earlier with a cold. He has stopped sneezing but still has a cough, especially at night. The patient is a heavy smoker who has often been advised to stop. Further history and examination reveal nothing special, apart from a throat inflammation. The doctor again advises the patient to stop smoking, and writes a prescription for codein tablets 15 mg, 1 tablet 3 times daily for 3 days.

Choosing a treatment and writing a prescription seems easymore difficult than it seems Requires a quite complex process of professional analysis, knowledge & systematic thinking scientific process clinical process therapeutic process

The result of treatment optimal/ maximal no risk (slight)

Rational Treatment
The process of choosing a treatment

Scientific process
Problem Therapeutic Objective Choose treatment Start treatment Monitor and Evaluation

In that case first choice tratment for dry cough

Treatment for suppres dry cough advice & drug therapy /P-drug P-drugs base on efficacy, safety, suitability, cost

How & not What to choose treatment

Therapeutics Process = process of rational treatment

The process of rational treatment

Step 1. Define the patients problem Step 2. Specify the therapeutic objective What do you want to achieve with the treatment Step 3. Verify the suitability of your P-treatment Check effectiveness and safety Step 4. Start treatment Step 5. Give information, instructions and warning Step 6. Monitor (and stop ?) treatment

1. Define the patients problem.

Disease or disorder Sign of underlying disease Psychological or social problems, anxiety Side effect of drugs Refill request (polypharmacy) Non-adherence to treatment Request for preventive treatment Combinations of the above Patophysiology, manifestation of desease

2.Specify the therapeutic objective.

What do you want to achieve with the treatment

prevent a lot of unnecessary drug use avoid unnecessary prophylactic prescribing to discuss your therapeutic objective with the patient before starting the treatment pharmacotherapy, non pharmacotherapy, or combination Not drugs as a placebo

Headache Diarrhea Cold Neurosis Dysmenorrhea Hypertension Sea sickness Rheumatism Cough Migraine Angina Pectoris 62 % 58 % 45 % 34 % 24 % 17 % 58 % 49 % 41 % 32 % 18 %

Beecher : 35 % in average (Geneesm. Bulletin, 23 Nov. 79)

Case 1 :
Girl, 4 years, slightly undernourished. Watery diarrhoea without vomiting for three days. She has not urinated for 24 hours. On examination she has no fever (36.8oC), but a rapid pulse and low elasticity of the skin.

Therapeutics objective : prevent dehydration


Case 2 :
Woman, 24 years. Consulted you 3 weeks ago, complaining of constant tiredness after delivery of her second child. Slightly pale sclerae, but normal Hb. You had already advised her to avoid strenuous exercise. She has now returned because the tiredness persists and a friend told her that a vitamin injection would do her good. This is what she wants.

Problem ? Ther. objectives help her reduce physical and emotional overload. non pharmacotherapy
(it may be necessary to involve other members of the family)

Intervention of therapy

3.Verify the suitability of your P-treatment

P-Treatment & P-Drugs
Not all desease need treatment with a drug P-treatment not always P-drug P-Treatmentadvice & information non drug treatment drug treatment referral for treatment combination of the above

Cases P-treatment: Constipation

Advice Drink a lot of fluids, eat fruit and high fibre food. Only go to the toilet when the need is felt. Do not try to pass stools by force. Reassure patient that nothing points to serious disease Non drug physical exercise Drug tx laxant Referral Not indicated

Acute watery diarrhoea with mild dehydration in a child

Advice cont breast feeding, observation Non drug fruit juice Drug tx rehydration solution (oral, NGT) Referral not necessary.

How do you manage to choose the right drug for each patient in a relatively short time? By using P-drugs!

Personal Formulary

The drugs you have chosen to prescribe regularly, and with which you have become familiar. They are your priority choice for given indications personal , priority Not only the name of drugdosage form, dosage schedule, duration of treatment Formulary essential drugs Enable you to avoid repeated searches for a good drug in daily practice You must up date your P-drugs evidence base

How to select a P-drug:

1. Define the diagnosis

2. Specify the therapeutic objective 3. Make an inventory of effective groups 4. Choose a group according to criteria: Efficacy, Safety, Suitability, and Cost Conclusion: Active substance, dosage form, Standard dosage schedule, Standard duration
How & not What to choose treatment

An inventory of effective groups of

drugs Angina Pectoris Drug Efficacy :
Site of action Angina Pectoris preload contractility frequency afterload Nitrates ++ ++ Beta Blockers + ++ ++ ++ Ca Antagonists + ++ ++ ++

Comparison between the three drug groups used in angina pectoris

1.Nitrates Efficacy

Side Effects


2.Beta Blokers Efficacy


Side Effects


3.Ca Antagonist Efficacy


Side Effects


Comparison between drugs within the group of nitrates

Efficacy Glyceril Trinitrat Sublingual Tab. O.4-1 mg OralTab. 2,6 mg Cap1-2.5 mg Transdermal 16-50mg Isosorbid Dinitrat Sublingual Tab 5 mg OralTab. 10-20 mg Retard Oral Tab 20-40mg Pentaeritritol Tetranitrat Oral Tab. 5 mg Isosorbid Mono Nitrat Oral Tab 10-40 mg Retard OralTab /Caps Safety Suitability Cost no difference

0.5-30 min 0.5-7 hours 1 - 24 hours 2-30 mnit 0.5-4 hours 0.5-10 hours 1-5 hours 0.5-4 hours -10 hours

4.Start treatment
write prescribing
Prescribing must be complete & every country

has its own regulations Name and address of the prescriber, with telephone number (if possible) Name of drug, dosage form, dosage scedule & duration of treatment Clear hand writing may be print out

5.Give information, instruction & warning

doctor-patient communication

Information Instructions Warnings

} ?

Drug & treatment

Doctor explained about taking drugs (why & how). The doctor just keeps on talking & talking doesnt encourage a dialogue. 50% Px do not take prescribed drugs correctly (irregularly or not at all)

Patient adherance
Therapeutic success

Non adherence to treatment

Elderly patients / too young patients Long time therapy Doesnt understand the aim of treatment Dosage schedule (regiment dose) is complicated for patients, particularly the elderly Side effects have occured Kurang percaya pada obat dan cara pengobatan Previuos bad experienced on take drugs Expensive drugs Symptoms have ceased etc

How to improve patient adherence to treatment

1. Prescribe a well-chosen treatment 2. Create a good doctor-patient relationship 3. Take the time to give information, instructions and warnings

How to improve patient adherence to treatment (cont)

A well chosen drug treatment consists of Considered P-drug Few drugs as possible (preferably only one), with rapid action, with as few side effects as possible Appropriate dosage form, with a simple dosage schedule (one or two times daily), and for the shortest possible duration

How to improve patient adherence to treatment (cont)

A good doctor-patient relationship Respect for the patient's feelings and viewpoint Try understanding and willingness to the patient In a dialogue, empowers the patient as a partner in therapy. Patients need information, instructions, warnings to provide them with the knowledge to accept and follow the treatment and to acquire the necessary skills to take the drugs appropriately

In some studies less than 60% of patients had understood how to take the drugs they had received. Information should be given in clear, common language Ask patients to repeat in their own words some of the core information, to be sure that it has been understood. Information A functional name, such as a heart pill is often easier to remember and clearer in terms of indication. Make a simple aids (leaflet, figure etc) Information to family/ other person for baby/elderly patients, invalid patients or non cooperative should be assitance to take drugs

The minimum information that should be given to the patient

1. Effects of the drug Why the drug is needed Which symptoms will disappear, and which will not When the effect is expected to start What will happen if the drug is taken incorrectly or not at all 2. Side effects Which side effects may occur How to recognize them How long they will continue How serious they are What action to take

The minimum information that should be given to the patient

3. Instructions How the drug should be taken When it should be taken How long the treatment should continue How the drug should be stored What to do with left-over drugs 4. Warnings When the drug should not be taken What is the maximum dose Why the full treatment course should be taken

The minimum information that should be given to the patient

5. Future consultations When to come back (or not) In what circumstances to come earlier What information the doctor will need at the next appointment 6. Everything clear? Ask the patient whether everything is understood Ask the patient to repeat the most important information Ask whether the patient has any more questions

Not Enough Time For Communication No, if doctor makes

personal formulary
- P-drug & P-treatment - information that need for P-drug

6. Monitor (and stop ?) the treatment.

Was the treatment effective ? A. Yes, and disease cured Stop the treatment B. Yes, but not yet completed Any serious side effects ? No : treatment can continue Yes: reconsider dosage or drug choice C. No, disease not cured Verify all steps